Www.myfloridalicense.com



| |STATE OF FLORIDA |FOR OFFICE USE ONLY |

| |DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION | |

| |2601 Blair Stone Road | |

| |Tallahassee, FL 32399-1011 | |

| |Phone: 850.487.1395 | |

| | | |

| |DBPR/hotels-restaurants/ | |

| | |Complaint # | |

| | |Date Received | |

|Section 1 – LICENSEE Information |

|License Type: | Food Service | Lodging | Elevator | Registered Elevator Company | Elevator Inspector |

| Name |

|      |

| Address |

|      |

| City | County | Zip Code |

|      |      |      |

| Business Phone | License Number (if known) |

|      |      |

|SECTION 2 – COMPLAINANT INFORMATION |

|Last Name |First |Middle |Title |Suffix |

|      |      |  |      |      |

| Organization Name (if representing an organization, please provide the name of the organization) |

|      |

|CONTACT INFORMATION |

| Primary Business Phone Number | Primary Home Phone Number |

|      |      |

| Primary E-Mail Address | Alternate Phone Number or Fax Number |

|      |      |

| Does the Complainant want to be contacted? | Yes No |

|MAILING ADDRESS |

| Street Address or P.O. Box |

|      |

|       |

| City | State | Zip Code (+4 optional) | Country |

|      |   |      |      |

|Section 3 – Details of the complAInt |

|      |

| Please provide any additional comments on an addendum. If addendum is used, please check here |

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